David Fawcett

UNDER THE RADAR: MENTAL HEALTH AND HIV RISK

  

This article was originally posted on TheBody.com on David's blog "Riding the Tiger: Life Lessons from an HIV-positive Therapist"

     Getting the level of new infections down to zero will require breakthroughs not only in medications and improved interventions, but also a broadening of our understanding about the underlying causes of high-risk behaviors which can increase vulnerability for HIV, specifically, mental health concerns.

    The emotional impact of diagnosis is clearly understood.   After all, who wouldn't be depressed upon hearing they have HIV?  Can we be surprised that a positive test result can be traumatic?  But what about the impact of depression or trauma on the risk of acquiring HIV?   Increasingly, we know that depression not only occurs after diagnosis,  but actually significantly increases the risk of becoming infected.  It is natural that trauma can result from seroconversion,  but we now know it is a major risk factor for HIV long before dangerous behavior takes place.  The earlier we identify and  intervene on these conditions the better chance we have of reducing the number of new infections.

    The following are just a few of the issues I feel should become increasingly integrated into our research and programming.

Depressive Disorders

    Numerous studies have documented the impact of depression on high-risk behaviors such as unprotected sexual intercourse, multiple sex partners, trading sex for money or drugs, and contracting sexually transmitted diseases, yet mental health is rarely a component of the design of HIV prevention and intervention programs.  Depression can lead to substance abuse, itself a high risk behavior, but even when studies control for substance abuse, depression alone remains a significant factor.  It leads to a sense of hopelessness and guilt, and severely impacts one's emotional resilience and self-esteem.  Depression leads to high risk behaviors which effectively distract or numb an individual from symptoms, but also greatly increase the risk of acquiring HIV or other sexually transmitted infections.

Sensation Seeking

    Defined as the need for thrilling, adventuresome, novel, and often dangerous experiences, sensation seeking is increasingly being identified as a separate phenomenon which can increase HIV-risk.  Sensation seeking can, of course, lead to substance abuse, but it can independently impact sexual behaviors (multiple partners, risky sex).  Men and women who seek increased stimulation appear to have a low tolerance for boredom, and contrary to common assumption, sexual compulsivity is not impulsive or pleasure-directed, but is associated with lower levels of self-esteem.   I have had clients, for example, who "act out" sexually not for pleasure but to manage emotional pain.  They seek to numb painful feelings by repeatedly having risky sex, and despite numerous sexual encounters, they end up feeling sad and "empty." 

Childhood Sexual Abuse

    Such abuse has been in the news recently and the statistics are truly shocking.  Prevalence studies of adults estimate that between 6 to 62 percent of women and 3 to 31 percent of men were sexually abused before the age of 18.  Many experts believe these numbers may actually be low.  Clearly, such a childhood experience is devastating both at that time and in later life.  The effects of trauma can lead to increased rates of addiction, sexual dysfunction,  depression, post traumatic stress disorder, and other significant concerns.   But what about risk for HIV?

    Childhood victims have a higher risk of becoming infected because of the long-lasting impact of abuse.  Such men and women are significantly more likely to become involved in sex work, to change sexual partners frequently, and to engage in sex with casual acquaintances.  They use larger quantities of addictive substances, and use them more frequently, and experience a disruption in the development of appropriate sexual behaviors.   Cleary, safer sex messages alone are largely ineffective for individuals whose lives have been disrupted by sexual assault.

Intimate Partner Violence

    Research has begun to document a correlation between risk of HIV and intimate partner violence (IPV).    Although both sexes can be vulnerable, the majority of persons experiencing IPV are female.   Possible mechanisms of increased risk include the consequences of forced sex and injury to the mucous membrane as well as an impeded ability to negotiate safe sex behaviors such as negotiating condom use or refusing sex.   IPV can predispose an individual to engage in sexually risky behaviors which in turn increase the risk of HIV infection.  A history of IPV can also negatively impact one's willingness to engage in voluntary HIV testing due to shame, stigma, or fear.  Once infected, a history of IPV, which is known to have immunosuppressive effects, can lead to a faster progression of the disease.    There are very few programs that address HIV and intimate partner violence risk reduction simultaneously, making this an area needing urgent attention.

Redefining the Epidemic

    To be truly effective, HIV prevention and intervention programs must broaden their scope to include a variety of other issues that directly impact the risk of acquiring HIV.  "Syndemics," or simultaneous epidemics, is a useful approach that more realistically reflects what I see in my office and in the community.  There are issues of HIV, other sexually transmitted infections, mental health disorders, addictions, trauma, and maladaptive behaviors such as sensation seeking that increase an individual's risk.    The HIV community, largely due to accidents of history, is divided by funding streams and professional training into separate silos that too often lack an integrated understanding of what any one individual is or has experienced that could put him/her at increased risk.

    We need to be certain our outreach and prevention efforts incorporate the effects of  mood disorders and behavioral concerns on sexual behaviors.  We need to understand that  all sexual behavior is not the result of free will but may, in fact, be driven by coercion or survival.    We need to understand that high risk sexual behavior or addictions may result from a history of childhood sexual abuse and integrate this information into our interventions.     To truly get to zero, we need to broaden our reach to all of the varied settings where vulnerability for HIV is born.   

AVOIDING THE SLIPPERY SLOPE TO BURNOUT

This article was originally posted on TheBody.com on David's blog "Riding the Tiger: Life Lessons from an HIV-positive Therapist"

The text alert came in the middle of a session.  It was from a colleague and read simply "call asap."  I dialed his number between patients and when he answered I was surprised at his quiet tone and his admission that he was really shaken.  We often utilized each other for consultation and support, but on this day he sounded defeated.  He told me that a patient had just died.  

This had, of course, happened before.  We both had spent the better part of our professional lives working with AIDS patients and their mental health concerns.  Simply due to the nature of the work, we had seen plenty of pain, both emotional and physical, and had experienced significant loss.  This patient had been a middle-aged man co-infected with HIV and hepatitis who succumbed to liver failure.  In the absence of any family, my colleague had invested extra effort fighting a disorganized health care system in an attempt to address his needs.  That frustration, combined with growing emotional exhaustion and ultimately his sense of failure that the patient died, made obvious to both of us that he was experiencing burnout.

Burnout Syndrome (BOS) was identified in the 1970s and  results from prolonged exposure to a variety of job stressors, ranging from long work hours (number of night shifts, time since last vacation, workplace organization or conflicts)  to emotional upheavals.  BOS is characterized by diminished emotional coping abilities, increased depersonalization (detachment and cynicism), and a low sense of personal accomplishment. It can be indicated in a variety of ways: long term exhaustion, feelings of failure, irritability and physiological symptoms such as headache and insomnia.

Healthcare professionals working with HIV/AIDS patients -- physicians, nurses, social workers, and other personnel -- are at a very high risk for Burnout Syndrome.  Some studies estimate that as many as 50% of workers in this field either currently or previously have experienced burnout.   There are even more specific risk factors within our ranks.    For example, younger workers experience more burnout than older ones.  Perhaps those that endure in this field develop coping mechanisms or have more control over their work environments.  Individuals with unresolved prejudice about sexuality or concerns about death may also be at risk.  Conversely, internally-based coping strategies, such as expression of feelings, patience, persistence, and a sense of optimism, appear to be protective factors.

What can be done about burnout?  Organizations can have a significant impact by carefully managing how staff and procedures are structured, as well as by focusing on communication and team building.  Individuals, as well, can employ a number of strategies to keep themselves emotionally fit and resilient.  Here are a few that will strengthen one's ability to keep burnout at bay. 

· Self care 

I frequently hear myself telling patients about the importance of self care: rituals of renewal that provide grounding for the turmoil we inevitably face on a daily basis.  These can take many forms: meditation, relaxation, physical exercise, healthy eating.  In my own life,  I know that these essential activities can often be deferred while other priorities vie for my attention.   It never fails, however, that if I invest time and effort in myself,  I am much more present and effective in my professional life.

· Interpersonal skills

There are common self-defeating patterns that contribute to work-related frustration and burnout which, once identified, can be easily corrected.  Among these are:

• Overreacting, that is, trying to find an immediate solution to every problem.  Answers may not always be immediately clear, or they may require some thought in order to reach a good decision.  
• Taking ownership of problems that are not our own.  Individuals in the helping professions frequently have co-dependency issues that contribute to the false belief that everything is our problem to solve.  Clear boundaries are essential to survive in this field.  
• Remembering to act on facts, not feelings.    If we are tired or worn down, it's easy to react on the basis of emotions (anger, hurt, fear) rather than facts.  It's important to take a step back, breathe, and get a sense of what is really going on inside.   Old feelings can often be triggered by present circumstances and sometimes seriously distract our focus.  

· Balanced Living

At a recent a workshop of healthcare workers in HIV/AIDS, I asked people to share how they employ recreation in their lives.   Surprisingly few hands were raised.  Many of the participants admitted they lacked a hobby, a passion, or any other recreational activity that got them physically and emotionally out of their workspace.  Our brains and bodies need balance in order to function well.  Remember that having fun is essential to one's health.   

· Connection

Whether through friends, family, partners, or spirituality, each of us needs a strong sense of connection to the world around us.   It is easy to get caught up in the drama of our professional lives and forget to nurture the other relationships that are essential for our wellbeing.   It is through these that we practice receiving love and support.  Many healthcare workers find it much easier to give rather than receive in their relationships and they often give until they are depleted.  In the end, giving and receiving must be in balance. 

The work we do is vital.  It can be emotionally and physically taxing, but it doesn't have to be personally harmful.  It we pay attention to our needs, acknowledge the other people in our lives, and monitor how smoothly we move through our day, we can create a professional life that is not only rewarding but sustainable as well.   

  

When the Crisis Lasts a Lifetime: HIV, Burnout, and Emotional Survival

Living with HIV creates one stressful event after another: anxiety about getting tested, dealing with news that one is positive, when to start medications, dealing with anxiety, depression and stigma...The list is endless.  It is critical that we learn how to manage these feelings because the toll created by chronic stress is directly related to a drop in CD4 counts.

At the recent Positive Living 15 conference in Fort Walton Beach, I gave this presentation on some ways to cope.  Here is a pdf verson of my presentation:

Download Positive Living 2012

The slides explain how stress impacts the body, symptoms, and tools to address them, including gaining a sense of optimism, improving interpersonal skills, identifying and appropriately expressing feelings, and most important, getting connected to others with whom you can give and receive support.  

Emotional survival with HIV is certainly possible but doesn't come without work, commitment, and sharing the experience with others.

The Endangered Wonder of the Positive Living Conference, and Why It Matters for Our Patients

Every spring, on the white, sandy beaches of the Florida Panhandle, an unlikely gathering takes place. On that narrow strip of land, between the Gulf of Mexico and Choctawhatchee Bay, 450 HIV-positive men and women from around the country, but mostly from the Southeast, come together amidst occasional spring breakers for a weekend of socializing, education, some silliness, a few tears, and just plain fun.

This year, the Positive Living conference turned 14, an extraordinary success by any measure, but even more poignant because it is the only remaining large-scale conference for persons living with HIV. It is a remarkable blend of individuals: Those who are well-known for their work in the field mix easily with positive men and women who may never have seen the ocean, or been able to spend a weekend by themselves at a hotel, or (most certainly) been around so many other positive individuals in one place.

I am always struck by the rich amount of valuable information available for both attendees and presenters. Tom Liberti, Florida's HIV/AIDS Bureau Chief, gives an annual review on the state of affairs, especially poignant this year because of the AIDS Drug Assistance Program crisis. There are medication updates and workshops on mental, physical and spiritual health. There is a daylong AdvocacyU workshop, where attendees learn how to use their voices to advocate on their own behalf.

And there is history. Until his death, Martin Delaney never missed Positive Living. And this year, as Martin Delaney did in years past, Paul Kawata, the executive director of National Minority AIDS Council, gave a keynote that captured a long-term view of HIV -- where we have been, our successes, our setbacks, our power, and the many struggles to come.

 

The heart of the conference lies with the participants, and it is here that the immense benefit for one's clients living with HIV can be clearly seen. Most receive scholarships, which pay for the beachfront hotel rooms and meals. Many are from the rural South and simply don't have adequate access to medical resources -- or, for that matter, each other. Positive Living fosters the formation of networks for both medical and social support; but mostly, at least for a few days, it normalizes the stigma of living with HIV. For one brief weekend, everyone is HIV positive (or a very close ally). One can feel a sense of joy and freedom in sharing this physical and emotional space.

The very existence of this conference is a tribute to the vision and hard work of Butch McKay, the executive director of a relatively tiny agency, Okaloosa AIDS Support and Informational Services, Inc. McKay and a handful of staff raise the necessary funds and organize this event with a mastery and focus that have a sense of life or death. And there is no doubt that Positive Living enhances, and even saves, the lives of persons living with HIV.

But the conference itself, like others before it, is at risk. Every year, fundraising is more difficult even as the need grows. Across many states vital programs are being cut, individuals are struggling with fewer resources, and bureaucratic shifts resulting from budget cuts make maneuvering the system, and surviving, that much harder. We witness our clients struggling with these issues every day.

It's easy to see why such events have disappeared. They require extraordinary determination to bring them to life, and the costs are daunting. But their demise represents one more great loss attributable to this virus. Without such gatherings, persons living with HIV have one less resource by which they can remain educated, connected, empowered and even sustained.

Too often we allow ourselves to focus on the objective data of HIV: CD4 counts, viral loads and years since diagnosis. Events such as Positive Living heal at a deeper, more subjective level: the spirit. They renew our determination as providers and they reenergize our clients' ability to integrate healing at multiple levels. For all this and more, they are well worth fighting for.

Volunteering Can Make You Healthy and Happy

    

Did you know that giving your time and effort on behalf of someone else can actually improve your mood and overall health?  Although it sounds too good to be true, that is the conclusion of a number of studies on a variety of populations from around the world.  Scientists are still unraveling the specifics, but there are some intriguing clues documenting the health benefits of volunteering.

    First, there are positive physical health effects.  Volunteering was associated with reduced mortality risk in a number of studies, especially in persons aged 60 and over, although the benefits appear to hold true for all ages.    Simply put, persons who consistently give their time on behalf of others lived longer than those who did not.  More surprisingly, the health status of the volunteer didn’t matter.  Even if they had a serious medical condition themselves, volunteering provided a protective factor for their own physical wellbeing.

     Volunteering was also associated with increased positive emotions and a significantly-improved  sense of purpose.   It increased access to social and psychological resources which countered negative moods such as depression and anxiety.  People who volunteered reported a greater degree of overall happiness, with improved social support and cohesion that benefits both the individual and the community.  Finally, volunteering has been shown to improve self-satisfaction and mastery of new skills, both of which reinforce a positive self-image.

    These studies also reveal interesting ways to maximize the positive effects of service work.  The total number of volunteer hours per week was not as important as consistency and length of service.  That is, just one hour a week was more effective at promoting the health and wellness of the volunteer than lots of hours, as long as it was consistent over a period of months or even years.    Studies also revealed that there are health benefits even if the service work is informal and privately arranged, such as spending time with a homebound neighbor each week.  Volunteer work doesn’t have to be “official” to benefit, just consistent.

    In the end, these studies showed that “mattering” was the crucial link between volunteering and wellbeing.  By moving beyond our own needs and helping others, we begin to make a difference and “matter” to both our community and ourselves, and we get the bonus of being healthier and happier.

David Fawcett, PhD, LCSW   

This article first appeared in Out in the News, Volume 3, Issue 1 (February-March 2010), a publication of the Broward County Health Department, S-Men Campaign for a Safer, Healthier Community.

DON'T BE INVISIBLE - JOIN "THE COUNT"

Did you ever wonder about the LGBTQ population where you live? How many of us are there? How old (or young) are we? What races and ethnicities do we represent? What is the status of our health, or our households, or our finances?

Today it is impossible to determine the answers to these questions, but if you live in Broward County that’s about to change. This summer you will be able to participate in an online census for the gay, lesbian, and transgender community called "The Count." The collected data will finally give us a statistical presence that not only provides an awareness of our numbers but also assembles information that can be used for public policy and funding decisions. The census is a collaborative effort that includes the United Way, Sunserve, the GLCC, Broward House, and the Broward County Department of Health. This is the first effort to quantify and document information about our community.

Why is this important? One key reason is that it will enable better funding for health care, social services, and other vital resources. For example, as Chair of the South Florida Methamphetamine Task Force, I have been frustrated in applying for funds that could provide additional treatment services because there is no specific data on the pervasiveness of substance abuse among Broward’s LGBT population. In the case of meth, we know there is a serious problem but grant makers want specifics, and documenting how many people are affected, their other health concerns (like HIV or Hepatitis), or their treatment needs is impossible because there is no data. This seriously affects our ability to get funding to help the community. If we aren’t seen or heard, we will be overlooked.

Many of my psychotherapy clients express frustration about what they perceive to be a lack of community. This census is an important step in affirming that we are not only here, but that we will be seen, heard, and counted.

"The Count" will go live this summer, but you can register now on the site to be notified about updates. For details go to www.lgbtcensus.com and help spread the word.

The Gay Men's Health Agenda 2009: Making our Voices Heard

As the new administration in Washington massively shifts national priorities, an opportunity has presented itself for the LGBTQ community to speak up and to be certain that our long-neglected healthcare needs are both recognized and addressed.

The Gay Men’s Health Agenda   is a significant document which grew out of a grassroots effort within the gay men’s health movement. After soliciting comments from gay men around the country, a draft was presented for feedback at the Gay Men’s Health Summit in Seattle in October, 2008, and the final version has now been published.

The Agenda is significant because it urges policy makers to recognize that the health care needs of gay men extend far beyond HIV/AIDS, and include mental health, substance abuse, external and internalized homophobia, and a sometimes appalling lack of cultural competency of many health care providers in recognizing and appropriately treating the health of the gay, lesbian, and trans community. This is even more vital as the federal government is now drafting "Health People 2020," which will serve as a roadmap for spending priorities over the next decade. Gays and lesbians have been virtually absent from federal health priorities. This Agenda pushes for change.

Recommendations specific to gay men’s health include funding and expanding social, behavioral, and biomedical research; developing and collecting data on sexual orientation and gender identity in federal research; funding campaigns to combat homophobia, biphobia, and transphobia; and eliminating bans on "promotion" of any type of sexual behavior, which impairs effective health campaigns. Other recommendations include creating strategies to combat health disparities, funding sexual health and wellness, and removing barriers to health care for transgender people.

Similar efforts for lesbian health include the Lesbian Health Fund of the Gay and Lesbian Medical Association. Health care disparities continue to grow for all of us in the LGBTQ community. These efforts are an important step in making our voices heard. Whether you participate by contributing to a similar document or by calling or emailing your representatives, be sure yours is among them!